Advance Directives

An advance directive is a written document that outlines your choices about the treatments you want or do not want, and who will make healthcare decisions for you if you become incapacitated and cannot express your wishes. An advance directive allows you to express your personal wishes and is based upon your own beliefs and values. When you make an advance directive, you have the opportunity to consider issues such as end of life care, being kept alive their machines, being independent and quality of life.

Traditionally, there are two main kinds of advance directives: the living will and the Durable Power of Attorney for Healthcare.

The state California also allows the use of a POLST (Physician's Orders For Life‑Sustaining Treatment). 

Anyone who is over the age of 18 and is of "sound mind" should consider making an advance directive. 

An advance directive speaks for you when you are unable to do so. Because it tells others the care and treatments you do or do not want and/or who will make healthcare decisions for you when you cannot express your wishes, it may relieve your family from the burden of guessing what you would want. Providing such guidance may also prevent painful family arguments about how you would want to be treated.

You will receive medical care regardless of whether or not you have an advance directive. However, there may be a greater chance you will receive the types of care and treatments you want if you have an advance directive.

If you cannot speak for yourself and do not have an advance directive, a physician will generally look to your family, friends or clergy for decisions about your care. If the medical center is unable to locate any family to act on your behalf, they may ask the courts to appoint a person (a guardian) who will make decisions for you.

An ethics consultation may be offered to help determine your goals and values in the absence of an advance directive.

These are not the same thing. It is generally a good idea to have all three because doing so provides greater guidance for ensuring that your values and preferences will be known in the circumstance when you cannot speak for yourself. However, there is no requirement that you have all of them.

A Living Will

A living will is a written statement in which you specify what kind of healthcare you do or do not want to receive. It can act as a guide for those who may need to make your medical decisions. A living will allows you to make decisions regarding treatment or machines that keep your heart, lungs or kidneys functioning when they are unable to function on their own.

Although you may write your living will on your own, it is best to inform your family, close friends and physician of your wishes.

Durable Power of Attorney for Healthcare

The power of attorney for healthcare is a form that allows you to appoint another person (a "healthcare agent") to make healthcare decisions for you if you are not capable of making them for yourself. When you complete this form, you give authority to your healthcare agent to make a wide range of decisions for you, such as whether or not you should have an operation, receive certain medications or be placed on life support. In some areas of healthcare, your healthcare agent is not allowed to make decisions for you unless you give him or her specific authority in these areas when you complete the form. These areas are listed on the form.

You can also include specific instructions about the type of treatments you want or do not want (such as surgery or tube feedings) when you complete the form. A power of attorney for healthcare goes in effect only when two physicians, or a physician and a psychologist, agree in writing that you can no longer understand your treatment options or express your wishes to others.

Physician's Order for Life‑Sustaining Treatment (POLST)

A Physician's Order for Life‑Sustaining Treatment (POLST) is a physician's order that outlines a plan of care reflecting a patient's wishes concerning care at life's end. Unlike traditional physician's orders, POLST is not bound to a particular site.

Rather, the orders contained within a POLST must be honored across care settings and hence may be used by EMTs, physicians and nurses in the emergency department, hospitals, nursing facilities, and so forth. In short, a POLST allows physician's order regarding end of life care to travel with a patient as the patient moves between home, the hospital, long‑term care facilities, etc.

Learn more about POLST

Advance Care Planning Class

Cedars‑Sinai offers a free class on the second and fourth Tuesdays of the month to help you complete your Advance Healthcare Directive form and guide your loved ones and caregivers in determining the treatment you want.

Find a class

Completing Your Advance Directive

Cedars‑Sinai provides an Advance Healthcare Directive booklet at the Plaza Level welcome desk (across from the Helping Hand Gift Shop).

You may also download, print and fill out the forms below:

For Religious Traditions

To ensure your wishes are honored in harmony with your faith, we’ve curated advance healthcare directive forms that respect different religious traditions.

• Catholic: Advance Healthcare Directive (PDF)(Opens in a new tab)
• Interfaith: Five Wishes Advance Healthcare Directive(Opens in a new tab)
• Jehovah's Witness: Advance Healthcare Directive (PDF)(Opens in a new tab)
• Jewish:
  • Jewish Advance Healthcare Directive (PDF)(Opens in a new tab)
  • Step‑By-Step Guide for Completing Your Advance Healthcare Directive (PDF)(Opens in a new tab)
  • Halachic Living Will of Agudas Yisroel (Orthodox) (PDF)(Opens in a new tab)
  • Halachic Healthcare Proxy of the Rabbinical Council of America (Orthodox) (PDF)(Opens in a new tab)
  • Medical Directives for Healthcare of the Conservative Movement (PDF)(Opens in a new tab)

Once completed, you should make several copies of you advance directive. A legible copy of an advance directive is acceptable. Find a safe place where you and others can easily find your copy, but we do not recommend you keep it in a safe deposit box.

Your family members and your lawyer, if you have one, should know you have made an advance directive and have a copy. You should also ask your physician to make your advance directive part of your permanent medical record. Without a copy of your advance directive, it cannot be used as a guide for your treatment.

Because your healthcare agent will make decisions for you based upon what he or she knows about you and thinks is best for you, it is important to choose someone who knows you well and to discuss your treatment preferences with him or her. You should choose someone who is willing to make the decisions you request in your advance directive. Your agent cannot be your doctor.

You can cancel or replace a living will or a power of attorney for healthcare at any time. The different ways you can do this are explained on the forms you complete when you make a living will or appoint a power of attorney for healthcare. A POLST can be changed as long as you have the capacity to request alternate treatments. If you lack decision making capacity, your surrogate may also request a change in conjunction with your physician.

The Advance Care Planning Group of Los Angeles

Medical treatment is intended to preserve life and improve its quality, yet when misdirected it can cause pain and suffering. Misdirected treatments may also reduce dignity and comfort at the end of life. In contrast, optimal healthcare involves planning for all stages of life to ensure care is consistent with each patient's values and goals, while adhering to medical standards. To promote our common goals of respecting individual values and reducing unnecessary suffering at the end of life, after extensive discussion our health systems are united in recommending₁:

1. Advance Care Planning should be standard medical care in our community and should be encouraged for all adults. Such planning involves discussing and documenting patient values, preferences, and goals to help guide healthcare professionals and families in providing appropriate future care. Physicians and members of the healthcare team₂ should encourage every patient with a terminal illness₃ who does not yet have an advance directive to engage in Advance Care Planning without delay — regardless of age.
2. Medical systems and healthcare providers should facilitate early access to palliative and other supportive services for all patients with chronic and progressive illnesses, when such services are available. Early education about and timely access to hospice services are essential for easing the dying process for patients with terminal illness₃.
3. Physicians should advise patients and families on the likely benefits and burdens of potential therapies and whether they are consistent with a patient’s known values and goals₄. These discussions should disclose whether any treatments under consideration may deprive the person of life closure (the ability to say "forgive me," "I love you" or "goodbye") or preclude a peaceful death.
4. Shared decision‑making is fundamental to optimal quality of care at the end of life. Physicians should engage in this process with patients or their legally recognized agent, while understanding that they are not obliged to offer or provide medically non-beneficial treatment₅. Medical staffs, medical groups, or healthcare systems should provide policies, such as those recommended by the California Medical Association₆, to guide physicians and healthcare teams when such care is requested. The healthcare team’s interactions with patients and families should demonstrate respect for all views and help guide the parties to a resolution consistent with applicable medical standards and laws.

References

1. Guidelines must be used in the context of clinical judgment and will not apply in all situations.
2. Physicians are uniquely positioned to take a leadership position in both providing medical expertise and in facilitating the team of other professionals who are integral to this process (nurses, social workers, chaplains).
3. Terminal illness is defined as any disease affecting one or more organs whose progression is not preventable, and commonly leads or contributes to death or manifest deterioration (mental or physical) within a predictable timeframe. End‑stage terminal illness often includes, though is not limited to, stage 4 disease of the heart or lungs, stage 4 cancer, or advanced dementia, as defined by: New York Heart Association (NYHA), Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria, National Comprehensive Cancer Network (NCCN), or Cognitive Performance Score (CPS). Patients with end-stage terminal illness would be expected to have a life expectancy of less than 6 months.
4. When a patient has not documented their expressed goals, values, and preferences, and cannot participate in decision‑making, a legally recognized healthcare decision maker may assist by describing their understanding of the patient’s goals, values and preferences.
5. In patients with late‑stage terminal illness, use of interventions such as renal dialysis, intravenous feeding, gastric food feeding, artificial ventilation, cardiopulmonary resuscitation or admission to an intensive care unit are generally non-beneficial and may cause an increase in pain and suffering (i.e. harm). Decisions not to comply with a patient or legally recognized healthcare decision maker’s request for medically non-beneficial treatment should be undertaken in accordance with California probate code sections 4734-4736.
6. CMA Model Policy: Responding to Requests for Non‑Beneficial Treatment.